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FP1.03 Perioperative Nasal Mupirocin to All Cases is More Effective than Preoperative Treatment of Only Nasal S. aureus Carriers in Reducing Orthopaedic Implant Surgical Site Infection (SSI)
Journal of Hospital Infection (2006) 64(S1) 1–110 Available online at www.sciencedirect.com
www.elsevierhealth.com/journals/jhin
Abstracts of the 6th International Conference of the Hospital Infection Society, 15–18 October 2006, Amsterdam, The Netherlands Oral Presentations FP1.01 MRSA PCR Testing of Patients Admitted to Critical Care R. Cunningham *, P. Jenks, S. Ferguson, J. Northwood, M. Wallis, S. Hunt. Derriford Hospital, UK Background: MRSA transmission is a significant problem in Critical care Units. Control measures may be less effective if delayed for the 2–3 days needed to confirm carriage, as patients with unsuspected colonisation may be a source of cross infection. Rapid diagnostic methods for MRSA such as PCR are now available, but have not been evaluated in routine UK clinical practice. Aim: To determine the effect of same day MRSA PCR testing at the time of admission to CCU on subsequent MRSA transmission rates. Methods: 612 patients were screened using standard culture methods between April 2005 and August 2005, and the IDI MRSA PCR test was used to screen 693 patients between September 2005 and February 2006. Standard infection control precautions were instituted when positive results were obtained by either method. Outcome measures included carriage rate, turnaround time for results and rate of subsequent MRSA transmission on the unit. Results: Overall carriage rate was 4.7% on admission to the unit. Culture results were available in three working days, PCR results within one working day. The mean incidence of MRSA transmission was 13.89/1000 patient days during the culture phase and 4.90/1000 patient days during the PCR phase (relative risk reduction 0.65, P < 0.05). Conclusion: PCR screening for MRSA on admission to Critical Care Units is feasible in routine clinical practice, provides quicker results than culture based screening, and is associated with a significant reduction in subsequent MRSA transmission on the unit. FP1.02 Costs of the MRSA ‘Search and Destroy’ Policy in a Dutch Hospital M. Van Rijen *, J. Kluytmans. Amphia Hospital, Netherlands Background: Methicillin-resistant Staphylococcus aureus (MRSA) has become an increasingly important pathogen in hospitals and recently also in the community. In Dutch hospitals the ‘Search and Destroy’ policy is applied successfully. Objective: The objective of this study was to determine the costs of the MRSA ‘Search and destroy’ policy over the years 2001 until 2005 in a teaching hospital with 1370 beds. Methods: Data of the Infection Control Department and from the hospital information system were used to calculate the variable and fixed costs. First, the isolation costs of both MRSA suspected and positive patients were calculated. Second, the costs of screening and isolation that were made when a patient or healthcare worker (HCW) was unexpectedly found to be colonized with MRSA were determined. These costs were © 2006 Published by Elsevier. All rights reserved.
further specified depending on the location of the index-case, and whether further spreading was found. Also, treatment of MRSA carriage, temporary closing of wards, cleaning etc were calculated. Results: In the study period 62 individuals (52 patients and 10 HCW) were found to be MRSA positive. 36 different MRSA types were found and one of them had spread in the hospital. This caused a temporary closure of 3 units for a total of 55 days. MRSA carriage of all colonized HCW was treated and together they were not allowed to work for 221 days. The salary of one fulltime infection control practitioner and the building of the isolation rooms in the hospital were the most important part of the fixed costs. Total costs of the MRSA policy was estimated at €413,833 or €2.16 per patient admitted to the hospital, or €0.29 per patient day. In the study period there were no patients that had a bacteremia caused by MRSA and only one patient developed an invasive infection with MRSA. Conclusion: A successful MRSA control policy was maintained at a cost of €2.16 per admission. The benefits were not determined in this study but are likely to be much higher.
FP1.03 Perioperative Nasal Mupirocin to All Cases is More Effective than Preoperative Treatment of Only Nasal S. aureus Carriers in Reducing Orthopaedic Implant Surgical Site Infection (SSI) R. Lee *, J. Pearman. Royal Perth Hospital, Australia Background: Patients having hip (H) or knee (K) implants at Royal Perth Hospital have been given prophylactic intravenous antibiotics routinely at induction of anaesthesia since 1976. Elective H or K implants on 181 patients during the 8 month period, 01/09/2000–30/04/2001, resulted in 6.6% having SSI; S aureus 1.7%, coagulase negative staphylococci (CNS) 2.2%. Kluytmans et al J Infect Dis 1995;171:216 showed that nasal carriage of S aureus was a major risk factor for wound infections after surgery. Consequently, all patients were screened for nasal carriage of S aureus 2–4 weeks before H or K implants and carriers were given a 5-day preoperative course of nasal mupirocin. Over 25 months (01/05/2001–30/06/2003) 805 H or K implants resulted in an SSI incidence of 5.3%; S aureus 1.6%, CNS 1.6% – not significantly different from before mupirocin. Aim: To compare the efficacy of 2 methods of using nasal mupirocin to reduce staphylococcal SSI following H or K implants: targeted preoperative treatment of nasal S aureus carriers versus perioperative prophylactic treatment of all cases. Methods: Following the report of Wilcox et al J Hosp Infect 2003;54:196–201 a 5-day perioperative course of nasal mupirocin was given to all patients having H or K implants from 01/11/2003. Results: During the first 26 months after introducing routine perioperative nasal mupirocin, 893 patients had elective H or K implants. 21 (2.4%) developed SSI; 1 with S aureus (0.1%), 9 with CNS (1.0%). The incidence of SSI was less than half the incidence when only nasal S aureus carriers were treated preoperatively
S2
Abstracts, 6th Int. Conf. of the Hospital Infection Society, 15–18 October 2006, Amsterdam, The Netherlands
(P < 0.005), largely due to the marked fall in S aureus infections (P < 0.0005). Conclusions: Preoperative screening and targeted treatment of only nasal S aureus carriers with nasal mupirocin did not significantly reduce SSI following elective H or K implants. However, routine perioperative prophylactic nasal mupirocin resulted in a significant reduction of SSI, due to a decline of staphylococcal SSI. FP1.04 Hospital at Home (HaH): Management of Patients Colonized/Infected by Methicillin Resistant Staphylococcus aureus (MRSA) J. Guillamont *, M. Sope˜ na, P. Biada, S. Gonzalez, A. P´ erezIturriaga, C. Davila, M. Fernandez-Casta˜ ner. Bellvitge Hospital, HaH, Spain Background: Staphylococcus aureus isolates resistant to methicilin (MRSA) reach rates of 5 to 10 percent in tertiary care institutions. Hospital-at-home care can be an alternative to inpatient care for managing patients colonized or infected by MRSA. Objective: Descriptive study of patients colonized/infected by MRSA attended at home. Description of gender, age, clinical picture, antibiogram, prevention measures at home, therapy to clear carriage or to prevent a carrier state by personnel of HaH team. Material and Methods: Patients with either colonized (group A) or with active infection by MRSA (group B) coming from early discharge from a tertiary hospital. Period July 2002–June 2006. Main criteria: (1) Living at el Prat or L’Hospitalet de Llobregat; (2) identified caregiver; (3) contact telephone; (4) informed consentment signed Staff personnel should wash hands with chlorexidine before and after attending patients and perform controls to detect possible nasal carrier. Re-admissions to hospital under 15% were acceptable. Results: 46 episodes corresponding to 24 patients with MRSA were attended, 18 men and 6 women. Average age 62.1 y. Average home period care: 10.2 days. Clinical picture: Group A: 36 episodes: Surgical wound cures, 16; COPD exacerbation, 6; P. aeruginosa infection, 5; heart failure, 2; urinary infection (E. faecalis) 1; sacral pressure ulcers 6. Group B: 10 episodies: surgical wound infection, 7; Pneumonia MRSA 2, necrotizing fasciitis, 1. Antibiogram: 8 differents resistance patterns were detected. Staff nares cultures were always negative. Discharge: 40 episodes were discharged to their GP and 6 had to be readmitted to hospital (13.04%). Conclusions: 1. HaH is a good alternative to inpatient care to release beds from MRSA. 2. Most episodes were discharged to primary care 3. Prevention measures among HaH personnel were succesful. 4. Re-admissions percentage was acceptable. FP1.05 The Transmission Dynamics of MRSA on Surgical Wards K. Hardy1 *, C. McMurray2 , S. Shabir2 , S. Gossain2 , P. Hawkey2 . of England NHS Foundation Trust, UK, 2 Health Protection Agency, UK 1 Heart
Background: Methicillin resistant Staphylococcus aureus (MRSA) is a major cause of hospital-acquired infection (HAI). EMRSA-15 and -16 are the dominant types within the UK, few studies have documented the transmission dynamics of these strains within an endemic setting. Aims: The current study aimed to determine the transmission dynamics of MRSA within surgical wards. Methods: All patients admitted to 7 surgical wards over a fivemonth period (Nov 05–Mar 06) had a nasal screen for MRSA on admission to the ward and then every 4 days. All MRSA isolates were typed using SIRU typing. The number of repeats at each of 7 loci were determined and a digital profile generated.
Results: A total of 2715 patients were included in the study, of which 99 (3.6%) were colonised with MRSA on admission to the ward and 116 (4.4%) appear to have acquired MRSA during their stay. A total of 51 different SIRU types were identified, of which 43 were subtypes of EMRSA-15, 1 subtype of EMRSA-16 and 9 others. Five types predominated of which 4 were subtypes of EMRSA-15 (96 patients) and 1 a subtype of EMRSA-16 (34 patients). Of the predominant EMRSA-15 subtypes, 44 patients were admitted colonised with the strain and 52 patients acquired the strain, compared to EMRSA-16 where only 9 patients were admitted colonised with the strain and 26 patients acquired the strain. Discussion: Longitudinal epidemiological typing of MRSA isolates in this study demonstrates that the type of MRSA which patients acquire whilst on the wards largely reflects the type that patients are colonised with on admission. However, the transmission ratio of EMRSA-16 was far greater than EMRSA-15. EMRSA-16 was represented by one type which may represent a more transmissible strain within the hospital environment. The ability of SIRU typing to identify genetic diversity within a population of EMRSA-15 illustrates that it is a rapid, transportable typing method that is able to investigate the micro epidemiology of MRSA. FP1.06 Monoclonal Vancomycin-Resistant Enterococci (VRE) Strain Detected by a Flagging System in Southern Israel R. Nativ *, A. Borer, P. Shlaeffer, E. Hyam, N. Porat. Soroka Medical Centre, Ben-Gurion University, Israel Background: Only recently, has VRE become epidemic in many acute-care hospitals (ACH) across Israel. Our aim was to devise a strategy for preventing the introduction of VRE to a VRE-free busy ACH in southern Israel. Methods: We created a flagging system that readily identified all newly admitted patients who have visited/admitted to other ACH in the preceding 6 months (risk group). Cultures for VRE (groin and axilla) were obtained from risk group patients on admission. Pending culture results (Protocol A), standard contact precautions and environmental disinfection were performed. In case of positive VRE (Protocol B), patients were placed in strict isolation. Patients that were in close contact with VRE carriers were treated according to Protocol A. Protocols were discontinued after decolonization was achieved (3 consecutive VRE-negative cultures). Additional inpatients not flagged for VRE were randomly screened. All VRE strains were subsequently analyzed by pulse field electrophoresis. Results: In all, 6269 consecutive admissions were studied, comprising 29% of hospital visits. Of 223 patients at risk (3.5% of admissions) subjected to Protocol A, the prevalence of VRE colonization was 4.4%, while no cases of VRE colonization were detected among 123 random controls (p = O.O16). All colonized patients were successfully decolonized after being subjected to Protocol B. No cases of cross-transmission were detected among 26 identified close-contacts. All VRE isolates were found to be a monoclonal strain. Conclusion: Introduction of VRE to non-endemic ACH can be successfully prevented even in the context of a nationwide epidemic. Screening for skin colonization with VRE on patient admission in our institution detects a predominant national clone. Strict active surveillance on patient hospital admission appears to be crucial to detect whether VRE strains can evolve into a polyclonal national endemicity as well as to prevent the dissemination of VRE in our institution.
www.elsevierhealth.com/journals/jhin
Abstracts of the 6th International Conference of the Hospital Infection Society, 15–18 October 2006, Amsterdam, The Netherlands Oral Presentations FP1.01 MRSA PCR Testing of Patients Admitted to Critical Care R. Cunningham *, P. Jenks, S. Ferguson, J. Northwood, M. Wallis, S. Hunt. Derriford Hospital, UK Background: MRSA transmission is a significant problem in Critical care Units. Control measures may be less effective if delayed for the 2–3 days needed to confirm carriage, as patients with unsuspected colonisation may be a source of cross infection. Rapid diagnostic methods for MRSA such as PCR are now available, but have not been evaluated in routine UK clinical practice. Aim: To determine the effect of same day MRSA PCR testing at the time of admission to CCU on subsequent MRSA transmission rates. Methods: 612 patients were screened using standard culture methods between April 2005 and August 2005, and the IDI MRSA PCR test was used to screen 693 patients between September 2005 and February 2006. Standard infection control precautions were instituted when positive results were obtained by either method. Outcome measures included carriage rate, turnaround time for results and rate of subsequent MRSA transmission on the unit. Results: Overall carriage rate was 4.7% on admission to the unit. Culture results were available in three working days, PCR results within one working day. The mean incidence of MRSA transmission was 13.89/1000 patient days during the culture phase and 4.90/1000 patient days during the PCR phase (relative risk reduction 0.65, P < 0.05). Conclusion: PCR screening for MRSA on admission to Critical Care Units is feasible in routine clinical practice, provides quicker results than culture based screening, and is associated with a significant reduction in subsequent MRSA transmission on the unit. FP1.02 Costs of the MRSA ‘Search and Destroy’ Policy in a Dutch Hospital M. Van Rijen *, J. Kluytmans. Amphia Hospital, Netherlands Background: Methicillin-resistant Staphylococcus aureus (MRSA) has become an increasingly important pathogen in hospitals and recently also in the community. In Dutch hospitals the ‘Search and Destroy’ policy is applied successfully. Objective: The objective of this study was to determine the costs of the MRSA ‘Search and destroy’ policy over the years 2001 until 2005 in a teaching hospital with 1370 beds. Methods: Data of the Infection Control Department and from the hospital information system were used to calculate the variable and fixed costs. First, the isolation costs of both MRSA suspected and positive patients were calculated. Second, the costs of screening and isolation that were made when a patient or healthcare worker (HCW) was unexpectedly found to be colonized with MRSA were determined. These costs were © 2006 Published by Elsevier. All rights reserved.
further specified depending on the location of the index-case, and whether further spreading was found. Also, treatment of MRSA carriage, temporary closing of wards, cleaning etc were calculated. Results: In the study period 62 individuals (52 patients and 10 HCW) were found to be MRSA positive. 36 different MRSA types were found and one of them had spread in the hospital. This caused a temporary closure of 3 units for a total of 55 days. MRSA carriage of all colonized HCW was treated and together they were not allowed to work for 221 days. The salary of one fulltime infection control practitioner and the building of the isolation rooms in the hospital were the most important part of the fixed costs. Total costs of the MRSA policy was estimated at €413,833 or €2.16 per patient admitted to the hospital, or €0.29 per patient day. In the study period there were no patients that had a bacteremia caused by MRSA and only one patient developed an invasive infection with MRSA. Conclusion: A successful MRSA control policy was maintained at a cost of €2.16 per admission. The benefits were not determined in this study but are likely to be much higher.
FP1.03 Perioperative Nasal Mupirocin to All Cases is More Effective than Preoperative Treatment of Only Nasal S. aureus Carriers in Reducing Orthopaedic Implant Surgical Site Infection (SSI) R. Lee *, J. Pearman. Royal Perth Hospital, Australia Background: Patients having hip (H) or knee (K) implants at Royal Perth Hospital have been given prophylactic intravenous antibiotics routinely at induction of anaesthesia since 1976. Elective H or K implants on 181 patients during the 8 month period, 01/09/2000–30/04/2001, resulted in 6.6% having SSI; S aureus 1.7%, coagulase negative staphylococci (CNS) 2.2%. Kluytmans et al J Infect Dis 1995;171:216 showed that nasal carriage of S aureus was a major risk factor for wound infections after surgery. Consequently, all patients were screened for nasal carriage of S aureus 2–4 weeks before H or K implants and carriers were given a 5-day preoperative course of nasal mupirocin. Over 25 months (01/05/2001–30/06/2003) 805 H or K implants resulted in an SSI incidence of 5.3%; S aureus 1.6%, CNS 1.6% – not significantly different from before mupirocin. Aim: To compare the efficacy of 2 methods of using nasal mupirocin to reduce staphylococcal SSI following H or K implants: targeted preoperative treatment of nasal S aureus carriers versus perioperative prophylactic treatment of all cases. Methods: Following the report of Wilcox et al J Hosp Infect 2003;54:196–201 a 5-day perioperative course of nasal mupirocin was given to all patients having H or K implants from 01/11/2003. Results: During the first 26 months after introducing routine perioperative nasal mupirocin, 893 patients had elective H or K implants. 21 (2.4%) developed SSI; 1 with S aureus (0.1%), 9 with CNS (1.0%). The incidence of SSI was less than half the incidence when only nasal S aureus carriers were treated preoperatively
S2
Abstracts, 6th Int. Conf. of the Hospital Infection Society, 15–18 October 2006, Amsterdam, The Netherlands
(P < 0.005), largely due to the marked fall in S aureus infections (P < 0.0005). Conclusions: Preoperative screening and targeted treatment of only nasal S aureus carriers with nasal mupirocin did not significantly reduce SSI following elective H or K implants. However, routine perioperative prophylactic nasal mupirocin resulted in a significant reduction of SSI, due to a decline of staphylococcal SSI. FP1.04 Hospital at Home (HaH): Management of Patients Colonized/Infected by Methicillin Resistant Staphylococcus aureus (MRSA) J. Guillamont *, M. Sope˜ na, P. Biada, S. Gonzalez, A. P´ erezIturriaga, C. Davila, M. Fernandez-Casta˜ ner. Bellvitge Hospital, HaH, Spain Background: Staphylococcus aureus isolates resistant to methicilin (MRSA) reach rates of 5 to 10 percent in tertiary care institutions. Hospital-at-home care can be an alternative to inpatient care for managing patients colonized or infected by MRSA. Objective: Descriptive study of patients colonized/infected by MRSA attended at home. Description of gender, age, clinical picture, antibiogram, prevention measures at home, therapy to clear carriage or to prevent a carrier state by personnel of HaH team. Material and Methods: Patients with either colonized (group A) or with active infection by MRSA (group B) coming from early discharge from a tertiary hospital. Period July 2002–June 2006. Main criteria: (1) Living at el Prat or L’Hospitalet de Llobregat; (2) identified caregiver; (3) contact telephone; (4) informed consentment signed Staff personnel should wash hands with chlorexidine before and after attending patients and perform controls to detect possible nasal carrier. Re-admissions to hospital under 15% were acceptable. Results: 46 episodes corresponding to 24 patients with MRSA were attended, 18 men and 6 women. Average age 62.1 y. Average home period care: 10.2 days. Clinical picture: Group A: 36 episodes: Surgical wound cures, 16; COPD exacerbation, 6; P. aeruginosa infection, 5; heart failure, 2; urinary infection (E. faecalis) 1; sacral pressure ulcers 6. Group B: 10 episodies: surgical wound infection, 7; Pneumonia MRSA 2, necrotizing fasciitis, 1. Antibiogram: 8 differents resistance patterns were detected. Staff nares cultures were always negative. Discharge: 40 episodes were discharged to their GP and 6 had to be readmitted to hospital (13.04%). Conclusions: 1. HaH is a good alternative to inpatient care to release beds from MRSA. 2. Most episodes were discharged to primary care 3. Prevention measures among HaH personnel were succesful. 4. Re-admissions percentage was acceptable. FP1.05 The Transmission Dynamics of MRSA on Surgical Wards K. Hardy1 *, C. McMurray2 , S. Shabir2 , S. Gossain2 , P. Hawkey2 . of England NHS Foundation Trust, UK, 2 Health Protection Agency, UK 1 Heart
Background: Methicillin resistant Staphylococcus aureus (MRSA) is a major cause of hospital-acquired infection (HAI). EMRSA-15 and -16 are the dominant types within the UK, few studies have documented the transmission dynamics of these strains within an endemic setting. Aims: The current study aimed to determine the transmission dynamics of MRSA within surgical wards. Methods: All patients admitted to 7 surgical wards over a fivemonth period (Nov 05–Mar 06) had a nasal screen for MRSA on admission to the ward and then every 4 days. All MRSA isolates were typed using SIRU typing. The number of repeats at each of 7 loci were determined and a digital profile generated.
Results: A total of 2715 patients were included in the study, of which 99 (3.6%) were colonised with MRSA on admission to the ward and 116 (4.4%) appear to have acquired MRSA during their stay. A total of 51 different SIRU types were identified, of which 43 were subtypes of EMRSA-15, 1 subtype of EMRSA-16 and 9 others. Five types predominated of which 4 were subtypes of EMRSA-15 (96 patients) and 1 a subtype of EMRSA-16 (34 patients). Of the predominant EMRSA-15 subtypes, 44 patients were admitted colonised with the strain and 52 patients acquired the strain, compared to EMRSA-16 where only 9 patients were admitted colonised with the strain and 26 patients acquired the strain. Discussion: Longitudinal epidemiological typing of MRSA isolates in this study demonstrates that the type of MRSA which patients acquire whilst on the wards largely reflects the type that patients are colonised with on admission. However, the transmission ratio of EMRSA-16 was far greater than EMRSA-15. EMRSA-16 was represented by one type which may represent a more transmissible strain within the hospital environment. The ability of SIRU typing to identify genetic diversity within a population of EMRSA-15 illustrates that it is a rapid, transportable typing method that is able to investigate the micro epidemiology of MRSA. FP1.06 Monoclonal Vancomycin-Resistant Enterococci (VRE) Strain Detected by a Flagging System in Southern Israel R. Nativ *, A. Borer, P. Shlaeffer, E. Hyam, N. Porat. Soroka Medical Centre, Ben-Gurion University, Israel Background: Only recently, has VRE become epidemic in many acute-care hospitals (ACH) across Israel. Our aim was to devise a strategy for preventing the introduction of VRE to a VRE-free busy ACH in southern Israel. Methods: We created a flagging system that readily identified all newly admitted patients who have visited/admitted to other ACH in the preceding 6 months (risk group). Cultures for VRE (groin and axilla) were obtained from risk group patients on admission. Pending culture results (Protocol A), standard contact precautions and environmental disinfection were performed. In case of positive VRE (Protocol B), patients were placed in strict isolation. Patients that were in close contact with VRE carriers were treated according to Protocol A. Protocols were discontinued after decolonization was achieved (3 consecutive VRE-negative cultures). Additional inpatients not flagged for VRE were randomly screened. All VRE strains were subsequently analyzed by pulse field electrophoresis. Results: In all, 6269 consecutive admissions were studied, comprising 29% of hospital visits. Of 223 patients at risk (3.5% of admissions) subjected to Protocol A, the prevalence of VRE colonization was 4.4%, while no cases of VRE colonization were detected among 123 random controls (p = O.O16). All colonized patients were successfully decolonized after being subjected to Protocol B. No cases of cross-transmission were detected among 26 identified close-contacts. All VRE isolates were found to be a monoclonal strain. Conclusion: Introduction of VRE to non-endemic ACH can be successfully prevented even in the context of a nationwide epidemic. Screening for skin colonization with VRE on patient admission in our institution detects a predominant national clone. Strict active surveillance on patient hospital admission appears to be crucial to detect whether VRE strains can evolve into a polyclonal national endemicity as well as to prevent the dissemination of VRE in our institution.